Safety: Restraints Using Restraints

Pre-procedure: Assess for risk of falls, level of awareness,

Restraints are a last resort. Provide consistency, keep
environment caregivers as consistent as possible. Encourage
friends & family to help w/care, bring familiar things from
home, help with adls. Review medications, therapeutic touch
and relaxation techniques. Most non invasive first,
discontinue non-needed agitating treatments, assess regular
for cognitive changes, speak clear, calmly, slowly, with a smile
facing the pt, reduce noise, good lighting, low bed if risk for
fall, bed alarms etc, extra rounding.
mobility status. Assess need for restraint, immediate physical
safety of pt, staff member, or others. Last resort.
Obtains a dr order for restraint, notify family of pt status & need
for restraints, pad bony prominences & apply appropriately
sized restraints (use a quick release knot when tying to frame of
wheelchair) Do not put restraints on the side rail. Adjust
restraint for good alignment, comfort, safety (slide 2 fingers in
wrist/ankle). Every 2 hours reassess, release.
Evaluation: Initial placement circulation, skin integrity, observe
for pallor or coolness, check restraint every 30 mins (more often
if behavioral), make sure restraint prescription is renewed every
24hrs if needed, modify plan of care. Remove asap

Restraints: Device or method used for the purpose of restricting freedom of movement or access to their own body with or without
permission. Can be mechanical, chemical, or material. By force person to person. **Can cause ulcers, bruising, nerve damage, emotional
distress.
Physical holding may not be considered a restraint if needed for test. Cast & traction are NOT considered a restraint. Less restraints = less
money, saves time, and reduces pt injury.
Joint commission: Promotes less restraint use, educate caregivers, document in great detail, maintain 1-1 viewing, budget. If use of restraints
release every 2hrs, reassess, let use bathroom, etc. Sometime necessary if irrational pt conflicting harm to himself, etc. Use bed alarms &
other devices instead if possible.
**Don’t use full length side rails unless client request it**